Form 1 Tax Return and Self-Assessment for the year 2017 (relating to taxes on income and capital gains)

2017150 Form 1 Tax Return and Self-Assessment for the year 2017 (relating to taxes on income and capital gains) TAIN GCD Remember to quote this number in any communication with your Revenue office Tax Reference Number Revenue On-Line Service (ROS) allows you to file this form and to pay any tax due electronically Access ROS at wwwrevenueie This Return form is for use by the following: (Indicate which one applies by inserting x in the appropriate box) Trusts - the return should be made by the trustees Estates under administration - the return should be made by the personal representatives Corporations and other bodies of persons - the return should be made by the treasurer auditor or receiver Returns by partnerships should be made on Form 1(Firms) Returns by individuals should be made on Form 11 Return Address Office of the Revenue Commissioners Collector-General's Division PO Box 354 Limerick RETURN OF INCOME CHARGES AND CAPITAL GAINS FOR THE YEAR ENDED 31 DECEMBER 2017 SELF-ASSESSMENT FOR THE YEAR ENDED 31 DECEMBER 2017 NOTICE You are hereby required under Sections 879 and 959I Taxes Consolidation Act 1997 to prepare and deliver to the above address on or before 31 October 2018 a statement for assessment to tax for the year 2017 and a statement of capital gains which accrued in the year 2017 On that date you must also pay any balance of tax due for 2017 If you file the return on or before 31 August 2018 Revenue will complete the self-assessment for you This will assist you in paying the correct amount by the due date Where this return is submitted after 31 October 2018 a surcharge (5% where the return is submitted within two months otherwise 10%) will be added to your tax liability Failure to submit your Local Property Tax return will result in a tax surcharge Expression of Doubt: If you have a genuine doubt about the correct application of tax law to any item in the return provide details of the point of issue in the entry fields provided on page 18 When completing this Return remember Write clearly and accurately within boxes Any panel(s) or section(s) that do not require an entry should be left blank In date boxes enter the format of Day/Month/Year eg 31/10/2017 Use BLUE ink when completing this form If there is not enough space in any of the panels provided on the form attach a separate schedule set out in the same format as the relevant panel(s) If submitting this return use any envelope and write Freepost above the Return Address You do not need to attach a stamp Legislative references relate to Sections of the Taxes Consolidation Act 1997 unless otherwise stated Civil Penalties/Criminal Prosecution Tax law provides for both civil penalties and criminal sanctions for the failure to make a return the making of a false return facilitating the making of a false return or claiming allowances or reliefs which are not due In the event of a criminal prosecution a person convicted on indictment of an offence may be liable to a fine not exceeding 126970 and/or to a fine of up to double the difference between the declared tax due and the tax ultimately found to be due and/or to imprisonment YOU MUST SIGN THIS DECLARATION The persons responsible for completion of this return are outlined above I DECLARE that to the best of my knowledge and belief this form contains a correct statement for the purposes of assessment to tax for the year 2017 and a correct statement of capital gains which accrued in the year 2017 Signature Date Capacity of Signatory Contact Details (in case of query about this return) Agent's TAIN Client's Ref Contact Name Telephone or E-Mail PAGE 1 RPC9544_EN_WB_L_1

REQUIRE AN ENTRY SHOULD BE LEFT BLANK A - DETAILS OF TRUST ESTATE CORPORATION OR OTHER BODIES OF PERSONS [1-9] 1 If there are any changes under the following headings not already notified to Revenue enter the new details here (a) Nature of Main Activity Address of first named Trustee Personal Representative Officer etc include Eircode (if known) 2 Mandatory Disclosure The number assigned to a disclosable transaction by the Revenue Commissioners under Section 817HB Disclosable transactions must be disclosed to Revenue under the Mandatory Disclosure regime and allocated a Transaction Number which must be included on the relevant tax returns Any transaction entered into which falls within one of the hallmarks of the Mandatory Disclosure regime (for example where it involves a discretionary trust which enables or might enable a person to obtain a tax advantage; and where obtaining that tax advantage is one of the main benefits of entering into the transaction) is a disclosable transaction Guidance on the Mandatory Disclosure regime is available on wwwrevenueie 3 Details of Trustee(s) Give the following information in respect of all Trustees If more than four Trustees attach a separate list set out in the same format Name Private Address include Eircode (if known) Date Appointed 4 Settlor Give the following information in respect of all Settlors If more than two Settlors attach a separate list set out in the same format Name Address include Eircode (if known) PPSN 5 Protector (if any) Give the following information in respect of all Protectors If more than two Protectors attach a separate list set out in the same format Name Address include Eircode (if known) PPSN PAGE 2

2017150 Tax Reference Number REQUIRE AN ENTRY SHOULD BE LEFT BLANK 6 Beneficiaries or Class of Beneficiaries Give the following information in respect of all Beneficiaries If more than two beneficiaries attach a separate list set out in the same format Beneficiary 1 Beneficiary 2 (a) Name of Beneficiary Address include Eircode (if known) (c) Tax Identification Number (d) Insert x in box if they were the beneficiary for the full year (e) If not the beneficiary for the full year enter the start and / or end date as appropriate Start Date (DD/MM/YYYY) End Date (DD/MM/YYYY) (f) If no longer a beneficiary at the time of filing this return insert x in the box 7 Other person exercising control Give the following information in respect of all other persons exercising control If more than two other persons attach a separate list set out in the same format Name Address include Eircode (if known) PPSN 8 Distribution of Assets (including cash) out of a Trust Date of Distribution Name and Address of beneficiary include Eircode (if known) Description of Asset (ie cash or otherwise) Value of Asset 9 Transfer of Assets (including cash) into a Trust Date of Name and Address of Transfer settlor/disponer/donor include Eircode (if known) Description of Asset (ie cash or otherwise) Value of Asset PAGE 3

2017150 Tax Reference Number REQUIRE AN ENTRY SHOULD BE LEFT BLANK B - IRISH INVESTMENT INCOME [101-108] 101 Irish Untaxed Income (a) Irish Government Stocks Irish Exchequer Bills (c) Irish Credit Union Dividends (d) Other Loans and Investments arising in the State 102 Irish Deposit Interest (a) Gross Deposit Interest received on which DIRT was deducted Gross Interest received from Special Share Account(s)/Special Term Share Account(s)/Special Savings Account(s) on which DIRT was deducted 103 (a) (i) Gross amount of Dividends from Irish Resident Companies (from which Dividend Withholding Tax was deducted) other than dividends received from a Real Estate Investment Trust (REIT) (ii) Gross amount of dividends received from a REIT Dividends from Irish Resident Companies from which Dividend Withholding Tax was not deducted (i) Gross amount of Dividends (ii) Amount of Dividends used for qualifying purposes in accordance with S 519(7) 104 Settlement Covenant Estate income etc (a) Type(s) of payment(s) Gross amount received/receivable where tax was not deducted (c) Gross amount received/receivable where tax was deducted 105 Patent royalty income where tax was deducted at source (a) Gross amount of Irish Patent Royalty income previously exempted under S 234 Gross amount of other Irish Patent Royalty income 106 Gross amount of Other Income where Irish Standard Rate Tax was deducted at source eg Annuities 107 Investment Undertakings (S 739G(2A)) (a) Gain on deemed disposal taxable at 25% (S 739E(1)(i)) Gain on deemed disposal taxable at 41% (S 739E(1)(ii)) (c) Gain on deemed disposal taxable at 60% (S 739E(1)(ba)) (d) Name & Address of the Investment Undertaking (S 739E(2A)) include Eircode (if known) 108 Income from Sources not shown elsewhere (a) Gross amount of income from sources not shown elsewhere Amount of tax deducted if any from this income (c) Details of income source(s) C - IRISH RENTAL INCOME [201-216] 201 *Where a claim to tax relief on property based incentive schemes is included at Lines 205(c) or 213 insert x in the box and give details in Panel K on pages 15 and 16 of this return Residential Property 202 Where the registration requirements of Part 7 of the Residential Tenancies Act 24 have been complied with in respect of all tenancies which existed in relation to residential premises in the year 2017 insert x in the box 203 Number of properties let 204 Gross Rent Receivable PAGE 4

205 Expenses (a) Repairs Allowable interest (e) Other 206 Amount of chargeable profit / allowable loss after expenses but before Capital Allowances and losses forward (a) Net profit on residential property Net loss on residential property Commercial property land and all other sources of Irish rental income 207 Number of properties let (a) PPS Number of tenant(s) (if known) Amount of Irish Tax Withheld PAGE 5 REQUIRE AN ENTRY SHOULD BE LEFT BLANK *(c) 'Section 23' type relief where 2017 is the first year of claim (d) Pre-letting expenditure on vacant properties allowed by S 97A 208 Area in hectares if applicable 209 Gross Rent Receivable 210 Expenses (a) Repairs Allowable interest (c) Exempt rental income from the leasing of farmland under S 664 (d) Other 211 Amount of chargeable profit / allowable loss after expenses but before Capital Allowances and losses forward (a) Net profit on commercial property Net loss on commercial property 212 Amount of chargeable profit from all sources after expenses but before Capital Allowances and losses forward (Total of Line 206 and Line 211 - if a loss show 0) Capital Allowances 213 (a) Capital Allowances brought forward from a prior year Note: As provided for in Part 12 Chapter 4A passive investors should not include any excess accelerated capital allowances carried forward beyond 2014 or the tax life of the building or structure if later * Capital Allowances for the year 2017 (c) Capital Allowances used against rental income in the year 2017 214 If you wish to elect under S 305(1) to set any unused Capital Allowances (not already ring-fenced) in respect of Buildings for 2017 against other income state the amount of unused Capital Allowances available for offset 215 Losses - Amount of unused losses from a prior year 216 Non-Resident Landlord If the trust is a non-resident landlord and the tenant has withheld tax from the rent state D - FOREIGN INCOME [301-321] (enter amounts in ) Foreign tax deducted should only be entered below if it is available as a credit against Irish tax If the foreign tax is only allowed as a deduction the amount of income returned below should be net of this foreign tax Where the foreign tax was refunded (or is refundable) by the foreign jurisdiction the gross amount of income should be returned below and the foreign tax should not be entered in this return See Guide to Completing 2017 Pay and File Self-Assessment Returns for more information on the taxation of foreign income 301 Great Britain and Northern Ireland Dividends Net amount received 302 UK Deposit Interest Gross amount of UK deposit interest

303 EU Deposit Interest (excluding UK interest) (a) Amount of EU Deposit Interest (c) Foreign tax (other than above) 306 Non-EU Deposit Interest (a) Amount of Non-EU deposit interest Amount of foreign tax deducted 307 US Dividends Enter gross amount (Enter the amount of Irish tax deducted if any on encashment of these dividends at Line 316) 308 Canadian Dividends where Irish tax on encashment was withheld Enter gross amount (Enter the amount of Irish tax deducted if any on encashment of these dividends at Line 316) 309 Canadian Dividends where no Irish tax on encashment was withheld Enter gross amount 310 Income from Foreign Trade/Profession on which no foreign tax was deducted 311 Savings Directive withholding tax credit (c) Foreign tax (other than above) 304 UK 'Other' Interest Gross amount of UK 'other' interest 305 EU 'Other' Interest (excluding UK interest) (a) Amount of EU 'Other' Interest Savings Directive withholding tax credit (a) Income from Foreign Trade/Profession on which foreign tax was deducted Amount of foreign tax deducted 312 Foreign Rents (a) Number of Foreign properties let (i) Amount of foreign tax deducted Foreign rental losses may be offset only against foreign rental profits 313 Other UK Income Income from all other UK Non-Deposit Interest Royalties Annuities Dividends etc Gross amount of UK Income from all Royalties Annuities Dividends etc Other Foreign Income (excluding UK Income) (Enter the amount of Irish tax deducted if any on encashment of this income at line 316) 314 (a) Foreign Patent Royalty income previously exempted under S 234 on which no foreign tax deducted Income from all other Foreign non-deposit Interest Royalties Annuities Dividends etc on which no foreign tax deducted PAGE 6 REQUIRE AN ENTRY SHOULD BE LEFT BLANK Income from Foreign Rents (enter gross amount receivable) (c) Expenses (i) Expenses relating to this income (excluding interest) (ii) Allowable interest (d) Net profit on Foreign Rental properties (e) Capital Allowances (including Capital Allowances forward) (f) Losses - Amount of unused losses from a prior year (g) Amount of losses in the year (h) Amount of losses carried forward to next year

REQUIRE AN ENTRY SHOULD BE LEFT BLANK 315 (a) (i) Foreign Patent Royalty income previously exempted under S 234 on which foreign tax was deducted (ii) Amount of foreign tax deducted (i) Income from all other Foreign non-deposit Interest Royalties Annuities Dividends etc on which foreign tax deducted (ii) Amount of foreign tax deducted 316 Irish tax deducted on encashment 317 Foreign Bank Accounts (S 895) Give the following details for each Foreign Bank Account opened in 2017 (a) Name & address of deposit holder (bank etc) include Eircode (if known) Date account was opened (c) Amount of money deposited on opening the account (d) Name & address of intermediary through whom account was opened include Eircode (if known) Foreign Life Policies/Offshore Funds/Other Offshore Products [318-321] 318 Foreign Life Policies (S 730H 730I 730J 730K) Give the following details in respect of any policy from any Member State of the EU or EEA or from a Member State of the OECD with which Ireland has a Double Taxation Agreement (a) Payment taxable at 41% (S 730J(a)(i)(II)) Payment (personal portfolio) taxable at 60% (S 730J(a)(i)(I)) (c) Gain (personal portfolio) taxable at 60% (S 730K(1)(a)(i)) (d) Gain taxable at 41% (S 730K(1)(a)(ii)) And in respect of any such policy issued in 2017 give the following additional details (e) Name & address of person who commenced the Foreign Life Policy include Eircode (if known) (f) Terms of the policy (g) Annual premiums payable (h) Name & address of the person through whom the Foreign Life Policy was acquired include Eircode (if known) 319 Offshore Funds (Part 27 Ch 4) Give the following details in respect of any material interest in 'regulated offshore fund(s)' (those coming within S 747B(2A)) in the EU or EEA or in a Member State of the OECD with which Ireland has a Double Taxation Agreement (a) Payment taxable at 41% (S 747D(a)(i)(II)) Payment (personal portfolio) taxable at 60% (S 747D(a)(i)(I)) (c) Gain taxable at 41% (S 747E(1)(ii)) (d) Gain (personal portfolio) taxable at 60% (S 747E(1)(i)(I)) PAGE 7

REQUIRE AN ENTRY SHOULD BE LEFT BLANK And in respect of any such material interest acquired in 2017 give the following additional details (e) Name & address of Offshore Fund(s) (f) Date material interest was acquired (g) Cost of acquisition to the person of the material interest (h) Description of that material interest (i) Name & address of intermediary (if any) through whom the material interest was acquired include Eircode (if known) 320 Other Offshore Products (S 896) Give the following details in respect of each material interest acquired in 2017 in (i) other offshore products (including foreign life assurance policies) outside the EU or EEA or outside a Member State of the OECD with which Ireland has a Double Taxation Agreement and in (ii) 'unregulated funds' (those not coming within S 747B(2A)) within the EU or EEA or within any Member State of the OECD with which Ireland has a Double Taxation Agreement (a) Name & address of Offshore Product(s) Name of person who commenced life policy (if appropriate) (c) Date material interest was acquired (d) Cost of acquiring the material interest (e) Description of that material interest (f) Name & address of intermediary (if any) through whom the material interest was acquired include Eircode (if known) 321 (a) Additional Double Taxation Relief due Details of income sources on which Double Taxation Relief due E - INCOME FROM TRADES PROFESSIONS OR VOCATIONS [401-450] Primary Trade 401 Description of Trade Profession or Vocation (You must clearly describe the trade) Do not submit accounts with this return Instead you must give an extract of information from the accounts in Extracts From Accounts Lines 415-450 402 If this source of income ceased during the year 2017 state the date of cessation Profit assessable in 2017 403 (a) Amount of adjusted net profit for accounting period 404 405 Amount of adjusted net loss for accounting period Enter the assessable profit even if this is the same as the adjusted net profit per Line 403(a) (if a loss show 0) This should include income assessable under S 98A(4) (Reverse Premiums in trading situations) where appropriate Balancing Charges 406 Unused Capital Allowances from a prior year PAGE 8

REQUIRE AN ENTRY SHOULD BE LEFT BLANK Capital Allowances for the year 2017 [407-410] 407 Where a claim to tax relief on property based incentive schemes is included below insert x in the box and give details in Panel K on pages 15 and 16 of this return 408 409 Machinery and Plant Industrial Buildings and/or Farm Buildings Allowance (Note: As provided for in Part 12 Chapter 4A passive investors should not include any excess accelerated capital allowances carried forward beyond 2014 or the tax life of the building or structure if later) 410 Other Capital Allowances Losses [411-413] 411 (a) If you wish to claim under S 381 to set any loss made in the trade in the year 2017 (other than a relevant loss as defined in S 381B) against your other income enter the amount of the loss Claim to be made on or before 31/12/2019 If you wish to claim under S 381 to set a relevant loss as defined in S 381B made in the year 2017 against your other income enter the amount of the loss Claim to be made on or before 31/12/2019 (Note: relief is restricted to a maximum of 31750) (c) If there are no/insufficient profits and you wish to claim unused current year Capital Allowances in computing a loss made in the trade in the year 2017 (S 392) enter the amount of unused Capital Allowances Claim to be made on or before 31/12/2019 (d) Total loss for offset against other income (by virtue of S 381 and/or S 392) Unused losses from a prior year 412 (a) Amount of unused losses from a prior year (S 382) other than residential development land losses where the relevant claim was not made to and received by Revenue before 7/4/29 In respect of unused residential development land losses from a prior year where the relevant claim was not made to and received by Revenue before 7/4/29 state (i) Amount of tax credit due in respect of these losses (S 644AA(6) and (8)) 413 (ii) Amount of tax payable on the profits or gains of the combined trade (S 644AA(7)) Terminal Loss Relief (a) If this trade ceased in 2017 and you wish to claim terminal loss relief for the years 2016 2015 and 2014 state (i) Amount of unused loss in the final 12 months to the date of cessation (ii) Amount of unused capital allowances in the final 12 months to the date of cessation If you wish to claim terminal loss relief for the year 2017 in respect of a loss made in a subsequent year state (i) Amount of the loss relief available for 2017 (ii) The date the trade ceased PAGE 9

REQUIRE AN ENTRY SHOULD BE LEFT BLANK Credit for Professional Services Withholding Tax (PSWT) 414 Gross withholding tax in the basis period for 2017 on fees for Professional Services EXTRACTS FROM ACCOUNTS [415-450] Accounts Information Period (must be completed) Primary Trade 415 416 From To Pages 10 and 11 must be completed in all cases where the Trust Estate etc is in receipt of trading or professional income except where either Lines 417 or 418 apply 417 418 If accounts information has been previously submitted relating to this return state the income tax return to which accounts were submitted (a) Where the income arises from a partnership enter the tax reference of the partnership Insert x in the box if you are a partner in a Registered Farm Partnership as defined by S 667C (c) Insert x in the box if this trade relates in whole or in part to Share Farming Y Y Y Y Income 419 Sales/Receipts/Turnover 420 Receipts from Government Agencies (GMS etc) 421 Other Income including tax exempt income Trading Account Items 422 Purchases 423 Gross Trading Profits Expenses and Deductions 424 Salaries/Wages Staff costs 425 Sub-Contractors 426 Consultancy Professional fees 427 Motor Travel and Subsistence 428 Repairs/Renewals 429 Depreciation Goodwill/Capital write-off 430 (a) Provisions including bad debts - positive If negative state amount here 431 Other Expenses (Total) PAGE 10

REQUIRE AN ENTRY SHOULD BE LEFT BLANK Capital Account and Balance Sheet Items Primary Trade 432 Cash/Capital introduced 433 Drawings (Net of Tax and Pension contributions) 434 (a) Closing Capital Balance - positive If negative state amount here 435 Stock Work in progress Finished goods 436 Debtors and Prepayments 437 Cash/Bank (Debit) 438 Bank/Loans/Overdraft (Credit) 439 Client Account Balances (Debit) 440 Client Account Balances (Credit) 441 Creditors and Accruals 442 Tax Creditors 443 (a) Net Assets - positive If negative state amount here Extracts from Adjusted Net Profit/Loss Computation Profit/Loss per Accounts 444 Net Profit per Accounts 445 Net Loss per Accounts Adjustments made to Profit/Loss per Accounts 446 Motor Expenses 447 Donations (Political and Charitable)/Entertainment 448 Light Heat and Phone 449 Net gain on sale of fixed/chargeable assets 450 Net loss on sale of fixed/chargeable assets PAGE 11

REQUIRE AN ENTRY SHOULD BE LEFT BLANK F - EXEMPT INCOME [501-502] 501 (a) Profit or gains from Woodlands If a loss enter the amount of the loss (c) Distributions out of exempt profit or gains from Woodlands 502 (a) Other Exempt Income Details of income source(s) G - SURCHARGE ON UNDISTRIBUTED TRUST INCOME [503-507] 503 Trust Income for the year ended 31 December 2015 (A) 504 Deductions (a) Allowable Trust Expenses Distributions of income arising in the year 2015 made on or before 30 June 2017 505 Total Deductions (504(a) + ) multiplied by 1 /80 (B) 506 Undistributed Income (A) - (B) 507 Surcharge @ 20% of Undistributed Income H - ANNUAL PAYMENTS CHARGES AND INTEREST PAID [601-604] 601 Gross amount of Rents etc payable to Non-Residents in 2017 602 Clawback of Employers Tax Relief at Source (TRS) If you are an employer and have paid medical insurance premiums to an authorised insurer on behalf of your employees enter the amount of tax relief at source granted to you in respect of these premiums Note: do not enter the amount of the insurance premiums paid 603 Gross amount of payment of other Charges/Annuity(ies) where tax was deducted 604 Significant Buildings and Gardens (S 482) (a) Amount of relief claimed in 2017 Insert x in the box if any of the qualifying expenditure was incurred under a passive investment scheme (S 409C) PAGE 12

REQUIRE AN ENTRY SHOULD BE LEFT BLANK I - CAPITAL GAINS - Capital Gains for the year 1 January 2017-31 December 2017 [701-717] 701 Description of Assets No of Disposals (a) Shares/Securities - Quoted Shares/Securities - Unquoted (c) Agricultural Land/Buildings (d) Development Land Insert x in the box(es) to indicate Aggregate Area in Hectares Aggregate Consideration (e) Foreign Life Policies (S 594) chargeable at 40% (f) Offshore Funds (S 747A) chargeable at 40% (g) Commercial Premises (h) Residential Premises (i) (j) Shares or Securities exchanged (S 913(5)) Venture Fund Gains (S 541C(2)(a)) (k) Other Assets (l) Total Consideration 702 If any disposal was between connected parties or otherwise not at arm's length 703 704 If any of the original acquisitions were between connected parties or otherwise not at arm's length If the market value has been substituted for the cost of acquisition of any assets disposed of Gains / Losses / Net chargeable gains 705 Chargeable gains in the year 706 Losses in the year 707 If any of the losses at Line 706 refer to a loss to a connected person give the following details (a) Name of connected person Tax Reference Number of connected person 708 (c) Amount of loss Chargeable Gain(s) (excluding Foreign Life Policies) net of allowable current year losses 709 710 Previous Gain(s) Rolled-over (now chargeable) Current year losses arising in 2017 available for offset against previous gains rolled over 711 Amount of unused loss(es) from prior year(s) available for offset against chargeable gains above 712 Net Chargeable Gain (excluding Foreign Life Policies) 713 Chargeable Gain on Foreign Life Policies 714 Unused Loss(es) for carry forward to 2018 PAGE 13

REQUIRE AN ENTRY SHOULD BE LEFT BLANK If you have an overall CGT loss in 2017 there is no need to complete Lines 715 or 716 715 In respect of net chargeable gains that arose in the period 1 January 2017-30 November 2017 (a) Enter amount of net gain to be charged at 33% Enter amount of net gain to be charged at 40% (excluding Foreign Life Policies) (c) (d) Enter amount of net gain on Foreign Life Policies to be charged at 40% (i) Enter amount of net gain in respect of a disposal of land under Compulsory Purchase Order (CPO) which has accrued in 2017 by virtue of S 542(1)(d) (ii) Date of disposal 716 In respect of net chargeable gains that arose in the period 1 December 2017-31 December 2017 (a) Enter amount of net gain to be charged at 33% Enter amount of net gain to be charged at 40% (excluding Foreign Life Policies) (c) Enter amount of net gain on Foreign Life Policies to be charged at 40% (d) (i) Enter amount of net gain in respect of a disposal of land under Compulsory Purchase Order (CPO) which has accrued in 2017 by virtue of S 542(1)(d) (ii) Date of disposal J - CHARGEABLE ASSETS ACQUIRED IN 2017 717 Enter the number of assets acquired and the consideration given Description of Assets Number of Assets Consideration (a) Shares (quoted and unquoted) Residential Premises (c) Commercial Premises (d) Agricultural Land (e) Development Land (f) Business Assets (g) Antiques/Works of Art (h) Other PAGE 14

REQUIRE AN ENTRY SHOULD BE LEFT BLANK K - PROPERTY BASED INCENTIVES ON WHICH RELIEF IS CLAIMED IN 2017 [801-833] You are required to provide the following information in support of your claim to any of the following reliefs You should note that the details required are the 'specified details' referred to in S 1052(1)(aa) and S 1084(1)(ib) and that any failure to fully and correctly complete this panel may leave you liable to penalties under S 1052 and/or a surcharge under S 1084 Enter the amount of the annual cost of the relief that is the amount claimed in the year excluding amounts carried forward into the year either as losses or capital allowances and before deducting any amount of unused losses and/or capital allowances which will be carried forward to subsequent years Residential Property Sections Investor - Lessor 801 Urban Renewal S372AP 802 Town Renewal S372AP 803 Seaside Resort S372AU 804 Rural Renewal S372AP 805 Living over the Shop S372AP 806 Park and Ride S372AP 807 Student Accommodation S372AP Industrial Buildings Allowance Owner Occupier Investor - Lessor 808 Urban Renewal S372C & D 809 Town Renewal S372AC & AD 810 Seaside Resort S352 & S353 811 Rural Renewal S372M & N 812 Multi-storey Car Parks S344 813 Living over the Shop S372D (Commercial premises only) PAGE 15 814 Enterprise Areas S343 815 Park and Ride S372V & W 816 Hotels S268(1)(d) 817 Holiday Cottages S268(3) 818 Holiday Hostels S268 (2C) 819 Guest Houses S268(2C)(a) 820 Nursing Homes S268(1)(g) 821 Housing for Elderly/Infirm S268(3A) 822 Convalescent Homes S268(1)(i) 823 Qualifying Hospitals S268(2A) 824 Qualifying Mental Health Centres S268(1C) 825 Qualifying Sports Injury Clinics S268(2B) 826 Buildings used for certain Childcare S843A purposes 827 Specialist Palliative Care Units S268(1)(m) 828 Buildings or Structures in Registered S268(2D) Caravan & Camping Sites 829 Mid-Shannon Corridor Tourism S372AW Infrastructure Investment Scheme

2017150 Tax Reference Number REQUIRE AN ENTRY SHOULD BE LEFT BLANK 830 Living City Initiative S372AAC 831 Living City Initiative (Investor only) S372AAD 832 Aviation Services Facilities S268(1)(n) 833 Where the scheme(s) on which you are claiming relief is/are not listed at Lines 801-832 state the name of the Incentive Scheme(s) quote the relevant Section and enter the amount of relief claimed in the year (Owner Occupier Investor-Lessor) L - SELF-ASSESSMENT MADE UNDER CHAPTER 4 OF PART 41A [901-902] This return must include a Self-Assessment by the chargeable person to whom the return relates An individual who fails to make a Self-Assessment may be liable to a penalty of 250 REMEMBER You do not have to complete the Self-Assessment panels if you submit this return to Revenue on or before 31 August 2018 901 Self-Assessment Income Tax 2017 (a) Amount of income or profits arising for this period (c) (Note: this is the amount of your total income for this year before taking account of any deductions reliefs or allowances Total income includes sources of income from employments pensions Department of Employment Affairs and Social Protection rental and investment income as well as self employed income Where you are in receipt of trading or professional income it is the adjusted net profit after taking account of business expenses but before losses forward or capital allowances) Total amount of tax chargeable for this period (i) Amount of tax payable for this period before refund/offset at (c)(iii) below (d) (e) (ii) Amount of tax overpaid for this period before refund/offset at (c)(iii) below (Note: this is the amount of tax payable or tax overpaid for the period which is computed by reducing the amount of tax chargeable ( above) by the amount of any tax credits due Credits include obvious items such as the personal tax credit or employee tax credit but also less obvious items such as Dividend Withholding Tax (DWT) withheld/deducted DIRT withheld at source PAYE operated on Schedule E income and Professional Services Withholding Tax (PSWT) This is the amount of PSWT withheld/deducted before any interim refunds already made by Revenue) (iii) Amount of refund (or offset) of tax withheld at source (Note: the amount of any tax withheld at source refunded (eg interim refund of PSWT) or offset should be entered here) Amount of tax payable for this period Amount of tax overpaid for this period (Note: this is the amount of tax payable or tax overpaid adjusted for any refund or offset of tax withheld at source already made by Revenue Where there is no refund or offset made the amount will be the same as (c)(i) or (c)(ii) above) (f) Amount of surcharge due under S 1084 because of late filing of this return (Note: if you are filing this return after the specified return date for the chargeable period a late filing surcharge is due If your return is late the surcharge which is added on to your tax due is 5% of the tax due or 12695 whichever is the lesser where the return is submitted within two months of the due date 10% of the tax due or 63485 whichever is the lesser where the return is more than two months late) (g) Amount of surcharge due under S 1084 because of non-compliance with Local Property Tax (LPT) requirements (Note: if you file this return on time but at the date of filing you have failed to submit your LPT return or have failed to either pay the LPT due or enter into an agreed payment arrangement a surcharge should be added to the final liability as if this return was filed late by two months or more Therefore the amount payable in your Self-Assessment should be increased by 10% subject to a maximum increased amount of 63485 Where the LPT is subsequently brought up to date the amount of the surcharge will be capped at the amount of the LPT liability payable) (h) Amount of tax including Preliminary Tax paid directly to the Collector-General for this period (Note: this is the amount of tax already paid to the Collector-General ie your 2017 Preliminary Tax paid Do not include any balancing payments which are now due and will be paid at the time this return is being submitted) PAGE 16

REQUIRE AN ENTRY SHOULD BE LEFT BLANK (i) (i) Balance of tax payable for this period (Note: this is tax payable amount at (d) above plus the amount of any surcharge due at (f) or (g) less the amount of tax already paid at (h)) (ii) Balance of tax overpaid for this period (Note: this is tax overpaid amount at (e) above less the amount of any surcharge due at (f) or (g) plus the amount of tax already paid at (h)) I DECLARE the above to be my Self-Assessment to Income Tax for the year 2017 Signature Capacity of Signatory Date 902 Self-Assessment Capital Gains Tax 2017 (a) Amount of chargeable gains arising for this period (Note: this is the amount of chargeable gains for this period less any reliefs which reduce the chargeable gain) Amount of tax chargeable for this period (Note: this is the amount of tax chargeable on the chargeable gain after taking account of any deductions reliefs or allowances eg personal allowance or transfer of business to a company) (c) Amount of tax payable for this period (Note: this is the amount of tax due after any Retirement Relief or Credit for Foreign Tax paid have been deducted from tax chargeable) (d) Amount of surcharge due under S 1084 because of late filing of this return (Note: see 901(f)) (e) Amount of surcharge due under S 1084 because of non-compliance with LPT requirements (Note: see 901(g)) (f) Amount of tax paid directly to the Collector-General for this period (Note: the amount entered here will be the amount of direct tax paid for the year plus any amounts that may have been credited to the year from another year or tax type) (g) (i) Balance of tax payable for this period (ii) Balance of tax overpaid for this period I DECLARE the above to be my Self-Assessment to Capital Gains Tax for the year 2017 Signature Capacity of Signatory Date The Revenue Commissioners collect taxes and duties and implement customs controls Revenue requires customers to provide certain personal data for these purposes and certain other statutory functions as assigned by the Oireachtas Your personal data may be exchanged with other Government Departments and agencies in certain circumstances where this is provided for by law Full details of Revenue s data protection policy setting out how we will use your personal data as well as information regarding your rights as a data subject are available on our Privacy page on wwwrevenueie Details of this policy are also available in hard copy upon request PAGE 17

REQUIRE AN ENTRY SHOULD BE LEFT BLANK Bank Details If you wish to have any refund paid directly to your bank account please supply your bank account details Single Euro Payments Area (SEPA) International Bank Account Numbers (IBAN) and Bank Identifier Codes (BIC) are generally available on your bank account statements Further information on SEPA can be found on wwwrevenueie It is not possible to make a refund directly to a foreign bank account that is not a member of SEPA IBAN (Maximum 34 characters) BIC (Maximum 11 characters) Note: Any subsequent Revenue refunds will be made to this bank account unless otherwise notified Expression of Doubt If you have a genuine doubt about the correct application of tax law to any item in the return insert T in the box and provide details of the point at issue in the entry fields below (This section is only for genuine Expressions of Doubt as provided for by S 959P It should not be used for general notes or comments) (a) Provide full details of the facts and circumstances of the matter to which the Expression of Doubt relates Specify the doubt the basis for the doubt and the tax law giving rise to the doubt (c) Identify the amount of tax in doubt in respect of the chargeable period to which the Expression of Doubt relates (d) List the supporting documents that are being submitted in relation to the matter involved These documents should accompany this return (e) Identify any published Revenue guidelines that you have consulted concerning the application of the law in similar circumstances PAGE 18 Designed by the Revenue Printing Centre